Psychodynamic Formulation

Psychodynamic Formulation

by Deborah L. Cabaniss, Sabrina Cherry, Carolyn J. Douglas, Ruth L. Graver, and Anna R. Schwartz. Wiley-Blackwell, New York, NY, 2013, 262 pages, $55.00 (hardcover).

This informative, thoughtfully organized, clearly written book addresses a central topic that is being ever more exiled into the shadows of psychiatric knowledge and practice. Like its companion volume, Psychodynamic Psychotherapy: A Clinical Manual (2011), also written by Deborah Cabaniss and her colleagues, Psychodynamic Formulation adds to the significant contributions on this topic from the Columbia Department of Psychiatry, notably those by Roger MacKinnon and Arnold Cooper.

As one who has been deeply involved in the practice of psychodynamic psychiatry and psychiatric and psychoanalytic education for over 40 years, I approached this book as a clinician and an educator. The experienced clinician will appreciate its wealth of information and superb bibliography but will also find its style and format too elementary and its clinical discussions too often superficial. The psychiatric educator, however, will discover an excellent framework for teaching the theory and practice of developing a psychodynamic formulation. Medical students, psychiatric residents, and other mental health trainees and recent graduates will find this volume succinct, useful, and practical.

Psychodynamic Formulation conceptualizes formulations as being psychodynamic when they consider "the impact and development of unconscious thoughts and feelings" (p 4) and stresses that "we formulate psychodynamically all the time—when we listen to patients, when we think about patients, and when we decide what to say to patients. Ultimately, formulating psychodynamically is a way of thinking that happens constantly in a clinician’s mind" (p 7). I believe that this frame of mind is essential to being a psychiatrist, and I think that the many clinical examples that fill this volume provide evidence to support this perspective. I doubt, however, that those whose knowledge and practice are not based on these principles will be persuaded by this book, nor do I think they will appreciate the application of this way of conceptualizing psychiatric disorders to cognitive-behavioral therapy, other psychological schools of thought, or pharmacotherapy.

The authors emphasize that any psychodynamic formulation should begin with a description of the patient from 5 perspectives: self, relationships, adaptation, cognition, and work and play. By stressing description, they implicitly highlight the importance of careful observation and psychodynamically informed listening, an especially timely reminder in this era of evidence in the practice of medicine. The initial assessment of the patient’s presenting problems and current functioning is followed by a thorough review of her/his personal history. This personal history can then be linked to the presenting problems and an initial assessment of the patient’s current functioning, and, with both current and historical understanding in mind, the clinician can develop an initial psychodynamic formulation.

Many case examples are included in each chapter, and, except for the penultimate chapter that explores revision in the psychodynamic formulation during long-term psychotherapy, they are short and often paired. The juxtaposition of 2 responses to the same clinical problem demonstrates the very different adaptive mechanisms that patients develop and reemphasizes that each psychodynamic formulation is unique. The brevity of the case examples creates a focused, incisive impact but comes at the cost, as I am sure the authors know, of an overly simplified formulation. To cite one example, a woman who seeks treatment for postpartum depression is hypothesized to have been impacted by her illness in a way that leaves her "feeling that she is a terrible mother and fearful about having a second child. These are new patterns that evolved in adulthood, which we can usefully link to the effects of a problem with mood on her sense of self" (p 156). This formulation would have been enhanced by considering the possibility that, long before she became pregnant, the patient was very frightened that she would be an inadequate mother and that this concern contributed to the development of her postpartum depression. Inexperienced readers will be unlikely to consider exploring this possibility; this is a potential risk inherent in the book’s format and style.

Psychodynamic Formulation stresses that all formulations are only hypotheses to be shared, at the appropriate time, with patients and then, through mutual exploration, to be tested over time. Many early chapters are devoted to an extensive discussion of human development, a perspective that heavily influences the formulations that are presented and one that has been deemphasized in much contemporary psychiatric literature. I was especially pleased to find a chapter devoted to the development of the psychodynamic formulation in a pharmacotherapeutic relationship, a treatment relationship that is often considered "medication management" rather than being understood as a therapeutic relationship involving the prescription of medication.

Psychodynamic Formulation is filled with clinical pearls: "When people suffer, we know that their functioning is faltering in some way" (p 18); "Challenge yourself to answer the question, ‘ Why did this person come to see me now?’ and you are likely to identify the primary problem" (p 18). Many others are included liberally throughout the book. Also generously scattered within its pages are important, highly useful pieces of information. To cite one example, the authors inform us that "children born to women who smoke during pregnancy have been found to have a 2- to 4-fold increased risk of ADHD, as well as suspected or definite psychotic symptoms" (p 84). Weaving such pieces of information into the text creates a work that is much more than a primer of psychodynamic formulation.

This book is addressed to students, recent graduates, and their teachers, but even medical students may find the level of conceptualization too lacking in subtlety. For example, in the chapter on "The Earliest Years," one comes across the statement, "When you build a house, the first thing you have to do is to lay a good foundation. It needs to be strong, but it also needs to be flexible enough to withstand future blows. The same is true for a developing person" (p 91). My concern is that readers who find this analogy unnecessary or beneath their educational level may devalue the centrality of the topic and not fully appreciate the authors’ sophisticated understanding of psychodynamic formulation. That said, this book should be required reading for all psychiatric residents and mental health students. Many recent graduates as well as experienced psychiatrists whose education was short on psychodynamic teaching will also learn much from this accessible, informed consideration of the psychodynamic formulation.

David I. Joseph, MD

[email protected]

Author affiliation: George Washington University School of Medicine and Health Sciences, Washington, DC.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2014;75(12):e1446 (doi:10.4088/JCP.14bk09341).

© Copyright 2014 Physicians Postgraduate Press, Inc.